Introduction: The success of colonoscopy for colorectal cancer (CRC) screening hinges on adequate bowel cleansing. Inpatient colonoscopies are routinely cancelled or rescheduled due to inadequate bowel cleansing at rates as high as 30-50%. Split-dose regimens are now standard of care, but there is institutional variability regarding the volume and formulation of laxative used. High-volume (4L) polyethylene glycol (PEG)-3350 electrolyte lavage solution (ELS) prior to colonoscopy is currently the conventional bowel prep. The aim of this study was to identify the number of inpatient colonoscopies that are cancelled at the Michael E. Debakey Veterans Affairs Medical Center (MEDVAMC) due to inadequate prep and identify possible solutions.
Methods: A retrospective cohort study was performed of inpatient colonoscopies scheduled during the period of 3/1/21 – 9/1/21 at the MEDVAMC in Houston, Texas. Data was collected through chart review through internal EHR. Type of bowel prep, volume of prep used, Boston bowel prep score (BBPS), and frequency of cases rescheduled due to inadequate prep were collected. Descriptive statistics were performed to identify baseline patient information and frequency of adequate prep (BPPS >/= 7). Vulnerabilities in the existing system were identified through a process map and fishbone diagram.
Results: A total of 135 inpatient colonoscopies were performed from 98 unique patients. 94 (96%) of the patients were male, 51 (52%) were white, 42 (43%) were African American, and 17 (17%) were Hispanic. 126 (93%) of the colonoscopies used split-dose 4L PEG-3350 ELS. 69 (51%) of performed colonoscopies had adequate colonoscopy preps and 33 (24%) of colonoscopies were cancelled or rescheduled. The average BBPS was 7.0 ± 2.1. Noncompliance with full prep solutions was identified in 9 of rescheduled cases. Supplementation with additional bowel prep agents was used in 38 (28%) patients.
Discussion: About 50% of scheduled inpatient colonoscopies performed at the VA hospital over 6 months was noted to be adequate bowel preparation. This is substantially lower than the performance targets for outpatient colonoscopies (e.g., >85%). Our process map and fishbone diagrams identified patient and staff-related factors as areas for improvement. Future interventions will focus on making bowel prep more tolerable for patients with high acuity illnesses (e.g., lower volume prep) and standardizing prep instructions and bedside analysis of pre-procedural stool color.
